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          <h1 class="post-title" itemprop="name headline">牙体牙髓病诊断与鉴别诊断相关问题</h1>
        

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        <p>曹莹老师<br>分类：龋病、牙髓病、根尖病、非龋性疾病、外伤。<br>诊断方法<br>一、问诊：<br>围绕主诉症状询问现病史<br>与主诉相关的既往史<br>全身系统性疾病及药敏史<br>注意：患者是否处于更年期、伴焦虑情绪、伴有精神心理疾病史<br>二、检查<br>口内检查顺序：主诉牙-非主诉牙-牙周-粘膜-其他问题<br>方法：视、探、叩、扪、咬、嗅<br>牙髓活力测试：温度、电活力。<br>牙髓活力测试-温度测试<br>冷、热测<br>部位：牙齿唇或舌面完整牙面的中1/3。<br>意义：检测进展性牙髓炎的有力诊断依据。<br>操作要点：<br>①先做对照牙，再测疑似患牙，还必须结合其它检查结果。<br>②冷诊：推荐小冰棒。三用枪出来的冷水是不准确的。<br>③热诊使用牙胶棒头部加热变软但不冒烟（如较长可能导致烫伤牙龈，受试部位不准确）<br>④热诊之前应使被测试的牙面保持湿润。(涂凡士林等）<br>⑤避免在病损部位和修复体表面做测试（假阴性或假阳性）<br>⑥热诊不作为常规检查项目，原因：可能损伤牙髓导致不可复性牙髓炎。<br>⑦重复测试时，应与上次测试有一定的时间间隔。<br>⑧选择对照牙：对颌或同颌同名牙，体积相近牙。<br>测试结果判读及临床意义<br>不用±，以正常、敏感、迟钝或迟缓性反应来表示。<br>a.正常：被测牙与对照牙反应程度和时间相同。<br>b.一过性敏感：测试时立即出现一过性疼痛反应，刺激去除后疼痛持续后消失，结合病史无自发痛，表示此时牙髓可能处于可复性炎症状态。<br>c.敏感：温度刺激引起疼痛反应，疼痛程度较重，刺激反应较快。刺激源去除后疼痛仍然持续一段时间，表示被测试牙有不可复性牙髓炎。<br>引起剧烈疼痛，甚至放散性痛，表示处于炎症急性期。<br>热痛冷缓解：急性化脓性牙髓炎。<br>d.迟钝：反应轻微，表示慢性炎症，牙髓变性或牙髓部分坏死。<br>e.迟缓性反应：慢性牙髓炎或牙髓大部分坏死。<br>f.无反应：牙髓坏死或变性。<br>电活力测试<br>禁忌：有心脏起搏器，严重心律不齐的患者慎用。<br>意义：只用于反映患牙牙髓活力有无，不能指示不同的病例状态，描述为有活力或无活力。<br>操作要点：<br>a.隔湿，干燥牙面，先做对照牙，再测疑似牙。<br>b.探头涂抹导电介质（常为牙膏），放于牙面，逐渐增大电量，直到有反应停止，记录数值。<br>c.首选温度测试。<br>d.注意隔湿及金属修复体的存在。<br>注意：外伤、钙化牙、牙髓部分坏死、根尖孔未发育完成等，测试结果不一定可靠。对照牙选同名牙或体积相等的牙。<br>三、影像学检查<br>1.根尖片：根管重叠的问题，偏移投照。<br>2.曲面断层片<br>3.CBCT<br>诊断步骤：<br>1.主诉症状<br>2.口腔检查<br>3.牙髓温度测验<br>在没有肯定患牙时，不要轻易对知识怀疑为牙髓炎的牙齿做牙髓治疗，不易诊断时，X线检查协助诊断。<br>深龋——鉴别诊断<br>1.可复性牙髓炎<br>①对温度刺激的反应<br>深龋通常在刺激物进入龋洞内时，才会出现疼痛反应，刺激去除后症状不持续。<br>可复性牙髓炎当刺激物接触完整的牙面后，可出现一过性敏感。<br>②难以区分，先按可复性牙髓炎的治疗进行处理。<br>2.慢性牙髓炎、死髓牙<br>①病史<br>②牙髓活力测试判明牙髓状态：若牙髓反应迟钝，则趋于慢性闭锁行牙髓炎。<br>③对于一时难以区分的，可先采用诊断性治疗方法，即去除龋坏组织后，间接盖髓，垫底，临时性材料充填后随访观察，在观察期内视其是否出现自发痛症状再明确诊断。<br>深龋治疗方法：<br>①安抚治疗<br>②间接盖髓<br>牙髓病的鉴别诊断<br>1.可复性牙髓炎<br>无自发痛史，<br>主诉对温度刺激尤其是冷刺激一过性敏感。<br>经安抚或间接盖髓治疗后，自觉症状消失，温度测试反应恢复正常。<br>2.急性牙髓炎<br>症状典型，牙髓温度测验可帮助定位患牙。（冷诊不明确一定要做热诊）<br>3.慢性牙髓炎<br>可以定位的患牙、病史、牙体疾患、叩诊反应可作为重要的参考指标。<br>不必分型。<br>4.残髓炎<br>属于慢性牙髓炎，有牙髓治疗史，强温度刺激患牙有迟缓性疼痛及叩痛，再治疗时根管内有疼痛。<br>5.逆行性牙髓炎<br>感染由牙周袋内的侧支根管开口或根尖孔引起的牙髓炎症，侧支根管的部位可在近牙颈部、根分叉和根尖1/3。是牙周牙髓联合病变的一型。<br>其它鉴别诊断<br>1.急性牙髓炎、牙龈乳头炎<br>牙龈乳头炎无阵发性疼痛，夜间痛。牙龈红肿，探诊疼痛。<br>2.深龋、可复性牙髓炎、慢性牙髓炎<br>前面已有。<br>3.可复性牙髓炎、牙本质敏感症<br>牙体表现不一样。前者常有牙体疾病。<br>4.急性牙髓炎、三叉神经痛<br>都有放射痛，前者有冷热痛，夜间痛。后者没有。<br>5.急性牙髓炎、急性上颌窦炎<br>后者有持续性闷胀痛，鼻部症状。无夜间痛。<br>6.牙髓息肉、牙龈息肉、牙周膜息肉。<br>把息肉扒开看其蒂部来源。<br>牙髓病的正确诊断名称<br>1.可复性牙髓炎<br>2.不可复性牙髓炎<br>(1)急性牙髓炎，包括慢性牙髓炎急性发作。<br>(2)慢性牙髓炎，包括，残髓炎<br>(3)逆行性牙髓炎<br>3.牙髓钙变<br>(1)髓石<br>(2)弥散性钙变<br>4.牙髓坏死<br>5.牙内吸收。<br>根尖周病诊断要点<br>急性根尖周炎<br>1.急性浆液性根尖周炎可由牙髓炎或咬合创伤等引起，可发生于活髓牙或失活牙上。<br>2.急性化脓性根尖周炎常由急性浆液性根尖周炎发展而来，也可由慢性根尖周炎急性发作而来。<br>根尖脓肿阶段，发展至骨膜下脓肿阶段，至粘膜下脓肿阶段。<br>X片，可无明显变化或仅有根尖区的牙周间隙增宽，若为慢性根尖周炎发作而来的，可见根尖不牙槽骨破坏的透射影像。<br>慢性根尖周炎<br>分三种，根据根尖片区分。<br>有窦型慢性根尖周脓肿和牙周脓肿的鉴别诊断：窦口探诊（深度、方向、有无溢出物），插牙胶尖拍X片的必要性（牙胶尖可指示病变的真正来源和方向）。<br>牙慢性损伤<br>1.磨损（咀嚼性和非咀嚼性）<br>2.楔状缺损<br>3.牙隐裂<br>不明显又疑有牙髓炎时，一定做牙髓温度测试。注意与牙本质敏感症相鉴别。<br>牙髓治疗的同时应做牙冠保护（推荐使用临时全冠或带环）。<br>牙外伤和其他牙体疾病（正确诊断名称）<br>1.牙震荡<br>2.牙折（≠劈裂牙）<br>冠折、根折、冠根折<br>3.牙脱位<br>挫入性（嵌入性）脱位、脱出性脱位、侧向脱位<br>4.牙本质敏感症（≠牙本质过敏）<br>5.牙根外吸收<br>6.牙齿变色<br>7.牙齿外源性着色</p>
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